How can a surgeon prevent bladder or ureteral injury during laparoscopic hysterectomy?
BARBER: I think the ureter is best identified by direct visualization transperitoneally. The angle of the laparoscope makes visualizing the ureter much easier than from an abdominal approach, so retroperitoneal dissection is not necessary as often. If the course of the ureter is not readily identified by direct transperitoneal visualization, a peritoneal incision can be made below and parallel to the infundibulopelvic ligament, which allows entry into the retroperitoneum and, typically, easy visualization of the ureter throughout its course. Alternatively, the retroperitoneum can be entered lateral to the infundibulopelvic ligament, and the ureter can be identified in the same manner as in abdominal hysterectomy. If laparoscopically assisted hysterectomy is planned, I prefer to dissect the bladder flap vaginally rather than laparoscopically, as the risk of bladder injury is considerably lower from a vaginal approach than it is laparoscopically. Obviously, if a total laparoscopic hyster
